- In 2019, there were 137 Medicare Advantage Plans available in Texas.
- 36% of the total Medicare population in Texas is enrolled in Medicare Advantage Plans as of 2018.
- In 2018, Original Medicare spent an average of $11,627 per beneficiary in Texas, which is 15% higher than the national average.
- Available Medicare Advantage Plans range from eight to 72 across Texas’s 254 counties.
The Medicare Advantage Plan you select affects out-of-pocket costs such as copays, deductibles, and premiums. Some plans require that you choose your primary care provider and obtain referrals to see specialists, while others are less restrictive. The availability of these plans depends on your health insurance provider and where you live.
Medicare Advantage Plans in Texas
Types of Medicare Advantage Plans
There are several types of Medicare Advantage Plans available in Texas, including HMOs, PPOs, PFFS, and SNPs, each with its own set of rules and cost-sharing obligations. Regardless of the plan type, Texas’s Medicare Advantage program provides at least as much coverage as Original Medicare Parts A and B.
Health Maintenance Organizations (HMO)
HMO Plans are the most common type of Medicare Advantage Plan. With this plan, you’re generally required to obtain medical care from in-network providers to pay the lowest prices for services. Some plans have a point-of-service option that lets you get care from an out-of-network doctor or hospital, but your copay is likely to be considerably higher. HMO Plans require that you choose a primary care doctor, and you need referrals to see specialists. Most plans include prescription drug coverage.
Preferred Provider Organizations (PPO)
PPO Plans are more flexible than HMO Plans. Like HMO plans, PPOs have in-network providers that offer you the lowest price for services. However, these plans cover care you get from out-of-network providers, although you can expect to pay more for services. You don’t need to choose a primary care doctor, and in most cases, you can schedule an appointment with a specialist without a referral. PPO Plans generally include prescription drug coverage.
Private Fee-For-Service Plans (PFFS)
With PFFS Plans, the insurance company determines how much it pays for health care services and your cost-sharing obligations. Some plans have full or partial provider networks, while others don’t have a network at all. Regardless of your plan’s network, you’re able to see any provider who agrees to the plan’s payment terms and conditions. However, you’ll pay the lowest out-of-pocket costs by staying in-network. If your plan doesn’t include prescription drug coverage, you can supplement it with a Medicare drug plan.
Special Needs Plans (SNP)
SNP Plans are special plans for individuals with certain diseases or conditions, such as those who are dually eligible for Medicare and Medicaid, live in a nursing home, or have severe or chronic illnesses. These plans provide tailored coverage for the groups they serve, including doctors and specialists, benefits, and drug formularies. You generally need to choose a primary care physician and get referrals to see specialists. All SNP Plans include prescription drug coverage.
Enrollment & Eligibility for Medicare Advantage Plans in Texas
In Texas, Medicare Advantage Plans are available to those who are at least 65 years of age or disabled, qualify for Original Medicare Parts A and B, and aren’t enrolled in a Medigap Plan. You must live in the service area of the plan you want to join. If you live in another state for part of the year, you may want to ensure your plan covers the care you receive there.
You can join or switch to a Medicare Advantage Plan at certain times, including:
- Initial enrollment period.This seven-month period starts three months before your 65th birthday, includes your birth month, and ends three months later. During this time, you can sign up for a Medicare Advantage Plan or a Medicare drug plan. If you were eligible for Medicare before turning 65 because of a disability, you could switch from your current Medicare Advantage Plan to a different one.
- Open enrollment period. This period runs from October 15th to December 7th every year. At this time, you can join a Medicare Advantage Plan or switch to a different one. As long as you submit your request during this period, your new coverage begins the following January 1st.
- Medicare Advantage enrollment period.This period runs every year from January 1st to March 31st. During this time, if you’re enrolled in a Medicare Advantage Plan, you can switch to a different one or back to Original Medicare.
Outside of these scheduled enrollment periods, certain life events trigger a special enrollment period. These include moving to a new address outside of your current plan’s service area, Medicare terminating your plan’s contract, or becoming eligible or losing eligibility for an SNP.
Prescription Drug Coverage
Medicare drug coverage helps you pay for the prescription medications you need. There are two ways to get this coverage: Enrolling in a Medicare drug plan (Part D), which can be added to Original Medicare or certain PFFS Plans, or enrolling in a Medicare Advantage Plan that includes drug coverage as a benefit. Even if you don’t take any medications when you first enroll in a Medicare Advantage Plan, it’s a good idea to find a plan that includes this coverage or add Part D coverage to your PFFS Plan to avoid penalties later on.
Medicare Advantage Resources in Texas
Texas is home to several agencies that provide information and support to help you select a Medicare Advantage Plan that fits your budget and health needs. The state’s Health Information, Counseling, and Advocacy Program (HICAP) counselors specialize in helping you evaluate your health care needs, compare the benefits and costs of the plans available to you. There are several ways to connect with HICAP counselors, including through the state’s Department of Insurance, local Area Agencies on Aging, and some nonprofit law firms.
Texas Department of Insurance
The Texas Department of Insurance publishes information useful to seniors in the state, including long-term care resource guides, Medicare supplement insurance guides, overviews of prescription drug plans, and information on recognizing insurance fraud. The department has an Area Agencies on Aging directory with up-to-date contact information, which you can use to find local HICAP counselors in your region.
Contact Information: Website | 800-252-3439
Harris County Area Agency on Aging
The Harris County Area Agency on Aging is headquartered in Houston, the state’s most populous city. It provides a range of services for those aged 60 and over, including case management and some legal assistance. It’s staffed with HICAP counselors who can help you identify and apply for Medicare Advantage Plans in your region, understand your benefits, and file disputes for denied claims.
Contact Information: Website | 832-393-4301
Texas Legal Services Center
Texas Legal Services Center is a statewide nonprofit organization that advocates on behalf of older residents. It administers HICAP in partnership with Area Agencies on Aging and the Health and Human Services Commission. It’s staffed with trained professionals who can help you compare available Medicare Advantage Plans, explain your medical bills, and guide you through the appeals process.
Contact Information: Website | 512-477-6000
Learn More from Our Sources
- Medicare | How Do Medicare Advantage Plans Work?
- Medicare | Medicare Advantage Plans
- Medicare | Health Maintenance Organization (HMO)
- Medicare| Preferred Provider Organization (PPO)
- Medicare | Private Fee-for-Service (PFFS) Plans
- Centers for Medicare & Medicaid Services | Private Fee-for-Service Plans
- Medicare | Special Needs Plans (SNP)
- Centers for Medicare & Medicaid Services | Special Needs Plans
- Medicare | Who Can Join a Medicare Advantage Plan?
- S. Department of Health & Human Services | Who Is Eligible for Medicare?
- Medicare | Joining a Health or Drug Plan
- Medicare | Special Circumstances (Special Enrollment Periods)
- Medicare | Drug Coverage (Part D)